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Our aim was to determine if the AUA-recommended prophylaxis (vancomycin + gentamicin alone) for primary inflatable penile prosthesis surgery is associated with a higher infection risk than nonstandard regimens.We performed a multicenter, retrospective study of patients undergoing primary inflatable penile prosthesis surgery. Patients were divided into those receiving vancomycin + gentamicin alone and those receiving any other regimen. A Cox proportional-hazards model was constructed adjusted for major predictors. A subgroup analysis to identify the appropriate dosage of gentamicin was also performed.A total of 4,161 patients underwent primary inflatable penile prosthesis placement (2,411 received vancomycin + gentamicin alone and 1,750 received other regimens). The infection rate was similar between groups, 1% vs 1.2% for standard vs nonstandard prophylaxis. In the multivariable analysis, vancomycin + gentamicin (HR: 2.7, 95% CI: 1.4 to 5.4,Vancomycin + gentamicin alone for antibiotic prophylaxis for primary inflatable penile prosthesis surgery is associated with a higher infection risk than nonstandard antibiotic regimens while antifungal use is associated with lower infection risk. A critical review of the recommended antimicrobial prophylactic regimens is needed. Prospective research is needed to further elucidate best practices in inflatable penile prosthesis antimicrobial prophylaxis.

Introduction Erectile Dysfunction (ED) has become an increasingly common disorder in young adult males. There are multiple etiologies of ED ranging from vascular, neurogenic, and structural causes. Often times, ED presenting in young men is psychiatric in nature as opposed to the other causes that typically present in older patients. ED found in young, healthy men with no history of systemic disease or traumatic injury, can be challenging. Past research has shown that men ages 18-35 typically have normal lab results and are treated with PDE-5 inhibitors. However, our data suggests that patients whose symptoms do not improve following the use of PDE-5 inhibitors may have a vascular etiology of ED. Objective Our objective is to determine the prevalence of venous leaks in young adult males who present with ED, but do not respond well to PDE-5 inhibitors. Methods Patients who underwent inflatable penile prosthesis (IPP) surgery for the treatment of ED over a 36-month period under the age of 35 who had failed PDE-5 inhibitors were identified from our database retrospectively. All patients completed an IIEF-5 questionnaire and had a penile doppler ultrasound (PDUS) performed preoperatively. PDUS was used to identify and record cavernous arterial flow signals before and after stimulation. Veno-occlusive ED was described as persistent End Diastolic Velocity (EDV) over 5 cm/sec during all phases of erection. The relationships, according to Doppler diagnosis, IIEF-5 score, SHIM scale, and erection score were evaluated as well as surgical outcomes and patient comorbidities. Results 1,558 patients were evaluated in this series, of whom 32 met inclusion criteria. Patients ages ranged from 18 to 35, with a mean age of 28.4. PDUS determined that 27 (84%) suffered from veno-occlusive disease, while 3 (9%) had arterial insufficiency due to DMI and 2 (7%) had neuropraxia. Of those veno-occlusive disease patients, EDV values ranged from 7.4 to 21.2, with a mean of 13.4, with peak systolic velocity values ranging from 45 to 122cm, with a mean of 97. All patients in this cohort had successful penile prosthesis implantation without complications or need for revision. Conclusions Doppler examination does indeed suggest that patients with cavernous venous occlusive dysfunction have moderate to severe leaks. We strongly recommend a baseline PDUS following PDE-5 inhibitor failure due to the significant prevalence of veno-ccclusive disease in this rare patient population. Furthermore, if veno-occlusive disease is identified during PDUS, we encourage frank discussion of penile prosthesis placement with the patient as well as the severity of veno-occlusive disease and its resultant effect of worsening ED. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: coloplast, boston scientific

Introduction Performing penile implant surgery can be challenging especially in the presence of a woody indurated penis (e.g. post priapism, post infection, prolonged h/o ICI, etc.) The loss of corporal smooth muscle cells and excess of collagen deposition caused by corporal fibrosis can create challenges and increase risk of perforation, crossover and certainly infection. Clinically, these fibrotic corpora make placement of a penile prosthesis a difficult surgical procedure. Objective We demonstrate how the Obturator Fenestration Technique facilitates placement of a penile implant in the woody indurated penis. Methods 48 y/o male w/ Hx of a 3-day Priapism treated with a shunt at the time. Patient was not offered a penile implant until 8 months following event. At the time of penile implant surgery the urologist placed a malleable halfway up on the right corpora and did not attempt the other side and case was aborted. Physical examination revealed diffusely woody indurated corporeal tissue throughout the left corpora and distally on the right corpora Results Penile implant was successfully implanted using the obturator fenestration technique in the woody indurated penis in the patient with a previously failed attempt at implantation. Conclusions The use of the Obturator Fenestration Technique can help facilitate increasingly complex cases This can help reduce unnecessary complications and repeat revision surgery. However, there is a learning curve while using the Obturator Fenestration Technique and should not be performed by a novice surgeon We hope to improve our techniques and surgical approaches to improve surgical times and post-operative outcomes for the woody indurated penis Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific

Introduction Inflatable Penile Prosthesis (IPP) is a common treatment modality for Erectile Dysfunction (ED). Previous studies have advocated the importance of undergoing a cystoscopy prior to an IPP procedure and whether the costs outweigh the benefits. Cystoscopies assist in diagnosing Lower Urinary Tract Obstructions (LUTO) such as BPH with obstruction, urethral strictures, bladder stones, and bladder tumors. These pathologies can cause complications in patients who undergo IPP, as well as unnecessary costs for canceling or aborting surgery. Due to these risks, cystoscopies may be a necessary pre-operative procedure prior to implantation. However, cystoscopies can be costly and there is an increased risk of infection. As a result, the cost-benefit analysis of performing this procedure in patients prior to IPP placement remains controversial. Objective To evaluate the prevalence of incidental findings found during cystoscopy, to determine if this procedure should be routinely implemented in clinical practice prior to IPP placement Methods We performed a retrospective study which identified all patients undergoing “de novo” IPP surgery, performed from May 2019 until May 2022, by two high volume implant surgeons. A review of all patients who underwent direct vision internal urethrotomy, or cystoscopy procedure prior to surgery was performed. The study population consists of men who underwent cystoscopy procedure prior to inflatable penile prosthesis (IPP) surgery in the office setting. Only patients who had no previous history of penile implantation were included. All clinical notes, patient demographics, comorbidities and surgical outcomes were reviewed. Results 224 patients met the inclusion criteria. Of the 224 patients who underwent cystoscopy, prior to implantation, 153 (68%) had no previous history of cystoscopy procedure, while 28 (12%) had prior robotic assisted laparoscopic prostatectomy (RALP). This cohort consisted of 40 (18%) patients whose cystoscopy findings lead to other urological procedures prior to IPP surgery. These findings included 15 patients with bladder outlet obstruction due to BPH, which required a TURP, 18 patients with previously unknown bladder tumors, which required a TURBT, and 7 patients with bladder stones which required cystolithotomy. Other incidental findings which did not require surgery included 24 (11%) patients found to have urethral strictures treated with traditional urethral dilation, with only 3 requiring cold knife therapy. 27 patients diagnosed with prostatic strictures secondary to previous prostatic procedures including TURP, Urolift, Microwave Therapy, cryotherapy, etc. These patients were dilated with the scope at the time of procedure. There were 3 patients that presented with kidney stones in the bladder which did not require additional procedures. Of this cohort, 8 (3.5%) patients had post-procedural infections that were treated with a conservative course of antibiotics and did not require further treatment. Conclusions In patients with no previous history of urologic evaluation, a pre-operative cystoscopy procedure can be an invaluable tool to help prevent unnecessary complications or misdiagnosed pathology, such as bladder cancer or urethral strictures. Unplanned intraoperative cystoscopies and interventions can be costly and may be avoided with a simple in office cystoscopy prior to penile implantation. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific

Introduction Penile prosthesis placement in men on active anti-coagulation (AC) is controversial. The bleeding risk of continued blood thinners must be weighed against the increased thrombotic risk for patients when stopping them. Previously utilized techniques to decrease complication rates from AC include the use of a malleable implant only, leaving the IPP partially inflated for hemostasis, and placement of a drain. Objective We sought to assess outcomes of penile implant placement in men on clopidogrel, warfarin, apixaban, enoxaparin, and rivaroxaban in a multi-institutional study. Methods Data from 3 high volume implant centers were retrospectively obtained. Demographic characteristics, comorbidities, case information including secondary procedures, placement of drain, drain output, and complications were recorded. Data on patients with aspirin any dose alone were not included as all 3 centers do not routinely discontinue ASA at time of penile implant. One center never placed drains and used a penoscrotal approach, one center left a drain at least one day and removed when output was < 50 ml/8 hours and used a penoscrotal approach, and the last center placed a drain for 3 days and utilized an infra-pubic approach. Results 202 patients were continued on AC throughout surgery. 112 patients were on clopidogrel, 35 warfarin, 38 apixaban, 1 enoxaparin, 15 rivaroxaban, and 1 on combination therapy with clopidogrel and enoxaparin. AC requirement included peripheral vascular disease (55%), CHF (11%), cardiac stents (11.6%), DVT/PE/history of thrombosis (7%), atrial fibrillation (11%), cardiac valves (2.2%), stroke (1.3%), and preventive (0.9%). Nine patients on AC (3.98%) experienced complications including 4 significant events (1.9%): 1 major retropubic bleed requiring transfusion, 3 IPP infections and 5 minor events: 3 minor hematomas, 1 minor wound dehiscence and 1 CT negative stroke event. Drain outputs for the 3 day center averaged 113 ml, 81 ml and 30 ml of output per day respectively with a total average output average of 223 ml and experienced no hematomas nor infections. Drain output for the center with removal when < 50 ml/8 hours averaged 121 ml with the majority or patients having the drain for only one day. Drain output was significantly higher than historical non AC controls (121 vs. 72 ml p=.001) but there was no difference in hematoma rate. Three hematomas and 1 infection occurred in this group. AC type, revision surgery, scrotoplasty, or reservoir technique did not affect outcomes nor drainage (P>.05). Complication rate (IPP infection and hematoma rate) where not different when compared to large cohorts from respective institutions. Conclusions Our data shows a 1.9% rate of major complications in patients undergoing IPP placement on anticoagulation in high volume implant centers. Although this approach appears feasible and similar in complication rates in men not on AC, careful consideration of the risk benefit ratio should be undertaken. Our data indicate closed suction draining for 3 days may be warranted. Additionally, the retropubic bleed case argues for only submuscular reservoirs placed under direct vision which minimizes occult bleeding risk. In the majority of cases, elective IPP surgery should be delayed until it is safe to discontinue anticoagulation therapy. Disclosure No

Placement of a 3-piece inflatable penile prosthesis (IPP) serves as definitive treatment for erectile dysfunction, and we sought to examine an alternative reservoir placement technique using the midline approach in patients with previous pelvic surgery. We highlight and describe the authors’ initial experience of midline reservoir placement for inflatable penile prosthesis. We collected data from patients with a history of bilateral inguinal surgery, unilateral herniorrhaphy, or a pre-operative physical exam revealing bilaterally patulous inguinal rings. The midline approach was performed on all patients undergoing IPP meeting the inclusion criteria from Feb 2018 to May 2020. Both virgin and revision IPP cases included. Intraop and postop morbidities were recorded. A segmented numeric version of the visual analog scale (VAS) was utilized to reflect pain intensity directly related to the midline approach to reservoir placement. Patients were evaluated for lower urinary tract symptoms in the preoperative and postoperative setting using the International Prostate Symptom Score (IPSS). A total of 125 (2 AMS 700 and 123 Coloplast Titan) patients underwent infrapubic IPP procedures utilizing midline reservoir placement. Of the 125 midline reservoir placements, 39 were revision cases, 3 of which underwent only reservoir exchange. The VAS (VAS range 0-10) was used to assess pain within one and at four weeks of follow-up. Midline reservoir placement was associated with minimal pain at the reservoir site, with all patients reporting a score of 1 at the four week follow up. Overall pain was also assessed with the VAS. At 1 week, mean VAS score was 1.86 (median 1, range 0-7). At four weeks, the mean overall VAS score was 0.56 (median 0, range 0-6). We describe a midline IPP reservoir placement that allows the surgeon to safely and effectively access the area posterior to the abdominal wall thereby precluding device palpability, while decreasing operative time, and minimizing patient reported pain at the reservoir site.

Introduction Disparities in disease incidence and outcomes are common in sexual medicine including erectile dysfunction (ED). As limited studies evaluate how ethnic disparities affect the way ED is treated, we used data from a high-volume center to investigate differences between Hispanic and non-Hispanic men following 3-piece inflatable penile prosthesis surgery. Objective To investigate differences between Hispanic and non-Hispanic patients undergoing Penile Prosthesis Surgery. Methods We performed a retrospective cohort study of two high volume implanters using records and data collected prospectively. Patient characteristics, comorbidities, and surgical outcomes were compared. Ethnicity was identified as Hispanic, non-Hispanic white, African American, and other. All patients completed a Sexual Health Inventory for Men (SHIM) questionnaire and had a penile doppler ultrasound (PDUS) performed preoperatively. We also employed the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) and the Visual Analog Scale (VAS) for Pain. Multivariate Analysis and logistic regression were used to identify the association between ethnicity, comorbidities, and surgical outcomes. Results 1,158 patients who underwent penile prosthesis surgery from April 2018 to June 2021, were evaluated. Most study participants were Hispanic (68.2%), with non-Hispanic whites counting for 22.5% of population followed by African Americans (8.6%) and other ethnicities ( Conclusions Despite younger age of disease progression at time of surgery, Hispanic ethnicity was an independent predictor of higher satisfaction rates and lower pain scores. Conversely Hispanics were found to suffer from more incidence of comorbidities when compared to NHW. This study suggests there may be disparities in disease progression and surgical outcomes between Hispanics and non-Hispanic whites. Further work is necessary to confirm this health disparity in other large datasets. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast and Boston Scientific

Introduction Erectile dysfunction (ED) following radical prostatectomy (RP) is a postoperative result that negatively impacts patient quality of life. The recovery of potency following radical prostatectomy varies depending on a multitude of factors including but not limited to surgical technique, surgeon experience and patient comorbidities. There are several factors that contribute to this decline in erectile function as a result of oncologic control after RP which may be classified as vasculogenic, neurogenic, and psychological. Current guidelines recommend patients wait up to 24 months before IPP surgery. However, no definitive algorithm or guideline has been established for the expedited management of ED in the postoperative setting following radical prostatectomy. Objective We are proposing an expedited algorithm for patients who fail PDE-5 inhibitors at the three-month follow-up following RP. Methods Patients who underwent inflatable penile prosthesis (IPP) surgery for the treatment of ED over a 36-month period following RP were identified from our IRB approved database. All patients completed an IIEF-5 questionnaire and had a penile doppler ultrasound (PDUS) performed preoperatively. Validated scoring for erectile function was performed with the International Index of Erectile Function (IIEF-5), and the Sexual Health Inventory for Men (SHIM) was defined. The relationships, according to Doppler diagnosis, IIEF-5 score, SHIM scale, and erection score were evaluated as well as surgical outcomes and patient comorbidities. Logistic regression and Wilcoxon rank sum tests were performed. Results 1,158 patients were evaluated in this series, of whom 121 met inclusion criteria. PDUS determined that 88 (72.8%) suffered from veno-occlusive disease, while 19 (15.7%) had arterial insufficiency. 101 (83.4%) had a RALP vs 20 (16.6%) who received an open RP. The mean time between RP and IPP was 20 months, with the mean ages of RP and IPP being 58 and 64 years respectively. Ages of patients ranged from 40 to 82 years old. Increased time between RP and subsequent IPP was correlated with lower SHIM scores. Additionally, each month that passed caused a decrease of 1.8% in SHIM scores (p< 0.05), as well as a greater likelihood of developing worsening vasculogenic ED (p= 0.042). Increased patient age during RP and subsequent IPP was also correlated with lower SHIM scores (p= 0.049), while RALP was found to be a predictor of higher patient satisfaction (p= 0.02). Conclusions As a result of the overwhelming diminishing SHIM scores over the 20 month postoperative course following RP as well as the significant prevalence of veno-ccclusive disease in this common patient population, we are strongly recommending a baseline PDUS at the 3 month followup. Furthermore, if veno-occlusive disease is identified upon the 3 month baseline PDUS, we encourage frank discussion of IPP placement with the patient. Equally important is it to consider discussing the degree of veno-occlusive disease and resultant ED will worsen as the postoperative period lengthens. Those patients found to have veno-occlusive etiology should have early surgical intervention mitigating further severity of the subsequent veno-occlusive disease. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast and Boston Scientific

To evaluate trends in the utilization of active surveillance (AS) in a nationally representative cancer database. AS has been increasingly recognized as an effective strategy for patients with small renal masses but little is known about national usage patterns.We identified patients with clinical T1a renal masses within the National Cancer Database in 2010 through 2014. Patients were classified according to initial management strategy received including AS, surgery, ablation, or other treatment. We characterized time trends in the use of AS vs definitive therapy and examined clinical and socio-demographic determinants of AS among patients with small renal masses using multivariable logistic regression models.We identified 59,189 patients who satisfied the inclusion criteria. Of the total cohort, 1733 (2.9%) individuals received initial management with AS, while 57,456 (97.1%) received definitive treatment. Surveillance rates remained below 5% in all years. On multivariate analysis, patient age (OR: 1.08, 95% CI 1.08-1.09), smaller tumor size of2 cm vs ≥2 cm (OR: 2.43, 95% CI: 2.20-2.7, P.0001), management at an academic center vs community center (OR: 2.05, 95% CI: 1.83-2.29), and African American vs Caucasian race (OR: 1.56, 95% CI:1.35-1.80) were independently associated with use of AS as initial management.In a representative national cohort of patients with small renal masses, we observed clinical and facility-level differences in the utilization of active surveillance in patients with T1a renal masses. Further investigation is warranted to better understand the forces underlying initial management decisions for patients with small renal masses.